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Joint | March 18, 2015 | Committee Room | Health and Human Services

Gentlemen I'm going to give it a couple of more minutes, we're slowly drifling in and we'll get started in just a couple of minutes, thank you. ladies and gentlemen in the interest of honoring everybody's time, I think we'll go ahead and get started, there's been some delays but people are on their way.
I call the meeting of oint Appropriations for helping human services to order, and this morning I'd like to first start off by recognizing our sergeant at arms from the house we have Young Bay, Bill Morris and Jimmy Ryan. From the senate Dale Huss and Marcus kiss. Thank you guys very much. For pages this morning from the house we have Ketley Johnson, she's from Hornick county and she's sponsored by Representative David Louis.
From the senate, we have Geisha Berg she's from Charlotte, she's sponsored by Senator [XX] and I will add a special note, it might take a moment and say a special hello to her. She's in the United States on a foreign exchange program, and we're very happy to have her visiting from Germany. Thank you very much for being here today.
If any other committee chairs have comments before we start this morning, I would like to recognize you, if not I I'm very excited about today's presentation, I really enjoyed the preliminary to this couple of weeks ago, or week ago, and this time I'd like to recognize Dr. Dorothy Cilenti, who is the Clinical Assistant Professor in the Department of Maternal and Child Health at the UNC Gillings School of Global public health.
Dr. [xx] welcome. Thank you Chairman [xx], am pleased to be here again I was here few weeks ago talking about children's health agezero to five and many of you were here for those of you who weren't here I'll just briefly introduce myself I am and faculty in the department of maternal child's health at the School of Public Health in Chapel

Hill but prior to joining UNC I was a local health director Almens and Chardem counties, and I'm health director in the Almens county and I also worked as Deputy Division Director at the division of public health at ATHS.
So my comments are framed around my experiences in the community and at the state with respect to women's health and children's health and also I was recently Chair of the North [xx] [xx] foundation so I've been involved with these issues wrong time and they're very many, and I appreciate the opportunity to speak with you about this topic.
So I'm going to start with the discussion of how healthy are North Carolina's mothers and babies, and when I was here last time I mentioned that the most vulnerable period for North Carolina and his children is the first year of life, and I'd like to talk a little bit more about why that is the health status for pregnant women and infants in North Carolina and also focus a little bit on health disparities and differences on birth outcomes based on some various social economic characteristics.
So during my presentation I'll share data on important health indicators for pregnant women and infants in North Carolina. I'll compare that information to the US as whole where available and also provide county's specific data where available. I will also discuss investments in maternal child health that may have the most impact what we are currently doing in North Carolina and then other efforts that you might want to consider.
So I think we all have similar goals for our babies and mothers in North Carolina. We know that the future prosperity of our state depends on and all of our babies being born with the same chance for healthy and productive life. We also know that when communities are well connected to resources such as high quality medical care, family support, education, jobs, a good public health system, access to healthy foods and places for physical activity.
We not only see better life outcomes but we see better birth outcomes as well. Also as we've discussed previously nine months of prenatal care is not sufficient to eradicate a life time of poor health for pregnant women. So we must ensure that our mothers have optimal health before they become pregnancy eat and deliver.
I want to talk a little bit about the Social-Economical Model, previously we talked about two models, we talked about the Life Course Model, which as you remember discusses risk factors and protective factors throughout life that impacts the continuum of health for an individual and then we also talked about the social determinant of health and how health is not just about adequate medical but all of the other factors that contribute to high quality of life.
We've pointed out that social factors impact a child's development and health. So this is another model or way of looking at the social determinant of health. Public health is based on Social-Ecological Model, which outlines how the health status of an individual is influenced not only by attitudes and behaviors of that individual, but also by the individual's relationships in their community and larger society.
There are variations on this model, but I'll look at how set us through a series of widening spheres of influence which can be either positive or negative. So this moves us then from thinking about the individual behavior that contributes to their success or their difficulties to taking a wider glance to better appreciate all the intercepting factors that influence them.
And notice here that even with the best intention or choices environment are still significant So what is the health status of our mothers and babies in North Carolina? So in 2013, which is the most recent data that we have, we had almost 120, 000 births in North Carolina and half of these births are paid for by Medicaid 2000 babies were born weighing less than 5 1/2 pounds, 84% of our babies were born to women between the ages of 18 and 34, and nearly 60% of babies are born to mothers who were married.
However nearly 50% of the mothers were obese or overweight before they gave

birth, and nearly 20, 000 babies were born to mothers with less than a high school education. So clearly there are some considerations as we look at infant outcomes. So let me talk a little bit about informality and just to remind you informality represents the numbers of babies who are born alive, but they die before there first birthday for ever 1, 000 live birth.
And infant mortality is widely used across the world as a measure of a health of a population, so it's more of a community health measure as well as a measure of infant health. It actually represent a tip of the ice berg because we don't account any infant mortality rates for the long term impact of the infant mobility such babies born with birth defects or other developmental challenges.
So let me talk a little bit about orient mortality rates since 1975. Clearly you'll see we've made remarkable progress in nearly the infomotality birth in North Carolina and in the United States. We had slight increases in North tarry infant mortality rates between 2011 and 2012, but this were not statistically significant differences.
We did have a stock low rate in 2010 which we matched inn 2013 of seven deaths for 1000 loive births. So, there is much to be proud of and it's clear that our investments in mothers and babies has really made a difference. However, when we look at the gap between United State which is currently at 6/1000 live births.
We can calculate that in order to get to the national rate we would need to save about 120 babies each year. and just as a point of reference our national rate is not comparable to other industrialized nations, so we have a lot to do in this country in terms of infant mortality. I wanted to show this map of the infant mortality rates just so you can see where the burden of excess infant deaths are pre-dominantly and you can see North Carolina is the among the states in the southern part of the country's south east with a highest infant mortality for mortality rate the darker areas of the map and then just in terms of the state in the bottom 10, North Carolina is 10th worse in infomotality which is an improvement in 1988 we were worse in the country and the state made great investment in women and children's health and we are now at about 40 years, so we still have a way to go.
So I want to switch over now to look at some of the disparities in the infant mortality rate because this is really where we need to think about making improvements, as you can see over the last 20 years, the infant mortality rates have dropped for the most part in all ratio and ethnic group. With the exception the American Indian population which has seen increases in infant mortality during this time period.
However, Africa-Americans consistently have the highest rates of infant mortality in the state. Over the last 20 years the ratio desperity ratio between whites and African American has varied over time. But African American rates have continuously been at least two times higher than infant mortality rates for whites, and it's actually a bit worse than it was in 1994.
We do have a healthy North Carolina 2020 objective as part of our health improvement plan to address and improve this gap in info mortality. The goal is by 2020 to reduce the despairity ratio to 1.2, which means that African American babies at 1.92 times greater risk of dying than white babies. Currently in 2013 the rate was 2.27, so we have up ways to go, and then I just want to comment on the info-mortality rates among

Hispanics that they are typically lower than other race on ethnic groups and this is shoes [xx] worth US the reasons are complex but there's some taking that though the culturein which Latin women are supported, supports positive maternal health behaviors and at the strong search of support system that appear play a role in improving mortality rate, however we noticed that over time that it vanished to a degree among that particular population.
So here is a look at our mortality for infants by counties, From 2009-2013, again the dark areas of the map represent the county that have a disproportionate number of babies dying before their first birthday. And where we have less than 10 deaths we don't represent that because those statistics are not reliable.
We do have Perinatal Care Regions in the state, and so I wanted to just show you how the infant mortality occurs by paranado[sp?] care region. We can see that the Eastern and South Eastern parts of the state have the highest rates of infant mortality, with essential part of the state having the lowest rate.
And we know too that the Eastern and South Eastern regions of the state are also regions of poverty rates and when we talked last time about children's health we also acknowledged that this part of the state is particularly burdened by poor child health outcome in general. So I wanted to shift to discussion about some of the causes of infant mortality and mobility because it is important to understand the nature of the issues in order to address them effectively.
So this pie chart describes the leading cause of infant deaths in 2013 for North Carolina and you can see that prematurity and low birth weight is the largest risk factor for infant deaths before the first year of life. Followed by birth defects, conditions of the mother and perinatal conditions.
All together these causes account for 65% of all of our infant deaths and North Carolina. And 2012-2013 we found that many of the post neonatal causes of death, these are the deaths that come after the first month of life, declined, in particular with the decline in birth defect in this population.
So just for clarification, other perinatal conditions may include birth trauma, maternal factors, complications of pregnancy labor and delivery, hypertension or new born complications. Maternal complications are responsible for about 16% of all infant deaths, so women you become pregnant, and then you have chronic conditions like asthma, or kidney disease, or diabetes, heart disease, alcohol and drug addiction are more likely to experience an infant death, and in addition acute conditions like infections may also complicate pregnancy and delivery, and cause an infant death.
I'm going to check brief ranges about seed test because we do see a decline and some unexpected infant deaths since 2008 when it was 12.8% and now it's at 2.8% in 2013. And some of this is a result of initiatives launched by the CDC, the sudden unexpected instant death initiative and these activities were aimed at improving investigation and reporting practices, so that they were be consistent reporting of these unexplained deaths.
So as a result, you now may see suffocation as a cause of death rather than sudden unexplained instant death. So cases that may have been formally attribute to cease may now be classified more specifically, and that's some of the reason I wish to just decline in this and condensed reports. I think it's important to point out the differences and the causes of death in the first 28 days and then

the 28 days through one year of life.
So neonatal death are primarily related to prematurity and birth defects and other paranoidal conditions almost 84%. Birth defects are responsible for 14-18% of all infant death in both periods but then looking at the post neonatal of period which is after the first month of life son unexpected infant deaths contribute to 40% of all the infant death during the first year of life.
And the decrease again that we saw from 2012 to 2013 and postneonatal deaths was largely attributed to a decrease in birth defects. so I mentioned that infant mortality is just a tip of the ice bug, we do have a significant challenge in North Carolina and nationally with low birth weight, low birth weight is 51/2 pounds or less and contribute to long term health conditons and developmental issues for children and this flied represents how a low birth rate rates are distributed across in North Carolina.
Again, children born at low birth way may experience developmental problems, short and long terms of disabilities and are greater risks of dying within their first year of life. Contributors to low birth weight include smoking, mother's poor nutritional status, poverty, stress, infections, violence and the areas of the state where the percentage of low birth weight birth are the greatest are in the dark areas and you see they overlap with our infant mortality rates that you stop previously.
Again African-American babies are more likely to be born at a low birth weight. I do want to mention very low birth weight, I don't have a slide for that, but very low birth weight put the infinite considerable rates of death. And this is the baby born at around three pounds, and we have a level three hospitals in the states that are studio to care for these babies but only 80% of our very low birth babies are actually born in these hospitals.
And so we need to continue to make sure that we identify the tyros pregnancies and assure that the babies are delivering in this treasury care settings where they can be cared for by the appropriate specialists. So poly-calysis is all about prevention and I wanted to just spend a minute talking about the risk factors that contribute to low birth weight, preterm birth, birth defects and some of the innovations that we've seen are effective in teenager in addressing these risks, so mother's nutritional standards we know is critical to preventing birth defects, preterm births, low birth weight and as is folic acid, and so the recommendation now is that all women at child bearing age, take a multivitamin with folic acid because we know that at 50% of our pregnancies are unintended, so if women became pregnant and they're lacking in folic acid or other nutritional requirements, then the babies are at risk of having these problems.
We also know that smoking is an area where we can intervene, and if we're able to get women to quit smoking during pregnancy, we would prevent 30% a low birth rate birth in the state. Alcohol use and substance abuse also contribute to poor birth outcomes and also chronic conditions of the mothers.
So obesity and overweight. You saw when we talked about children's health the degree to which children are impacted by obesity and overweight, and how difficult it is to achieve typical weight or normal weight when you start out as a child with weight related issues. Women with diabetes also are at risk for delivering a baby with low birth weight or birth defects, and I mentioned infections also as contributing to these problems.
And then also the environment and social stresses have been documented to contribute to pre-term birth and low birth weight as well. So we know we there are ways we can intervene effectively to reduce these risks and improve

the likelihood of a positive birth outcome. So I'm just going to go into a few of these factors to see you can see this sign may be a little bit difficult to read, but in terms of smoking during pregnancy we know that it's decreasing but it's still a matter of great concern and demands attention.
Three of the top four causes of infant death in North Carolina are directly associated with either maternal smoking during pregnancy, or infant exposure to tobacco smoke after birth. And we know that over one in ten babies in North Carolina are born to women who report using tobacco during pregnancy.
Tobacco use again is the number preventable risk factor for low birth weight, studies have shown that maternal smoking accounts for up to 30% of infants were born less than 5.5 pounds and in North Carolina mothers who smoked during pregnancy had nearly twice the risk of an infant death or low birth weight baby the mothers who did not smoke.
So this map shows variation in maternal smoking by counties. So the dark areas is the heaviest smoking with the lighter areas fewer women smoking and as you can see that we have 14 counties at least where maternal smoking is double the state rate average, which means more tat one in five pregnant women are smoking during pregnancy.
And we also know that for every dollar invested in tobacco association for pregnant, we see a return of $3 and saved to health care cost. So this is a very powerful intervention. So what are some of the protective factors, if you remember last time we talked about the life force model and the need to have protective factors outweigh the number of risks factors, and there are things that we know make a difference in terms of birth outcomes.
One of this is receiving time prenatal care, so early prenatal is necessary but not sufficient. It identifies maternal risk factor and addresses health concerns before they present a problem for the mother and the infant, and this graph shows, the percent of North Carolina births by which trimester the mother received care, so you seem 70% of our women enter prenatal care within the first three months of pregnancy, but 28% of women do not receive prenatal care until the second or third trimester of pregnancy and 2% receive no prenatal care which is pretty significant when you're 120 000 births per year.
We also know that there are ratios desparities with prenatal care with minorities being less likely to receive early care, so 21% of whites receiving late care versus 40% of Hispanics, 36% of African American women and 33% of American Indian women. I also want to mention that, over the course of the last several years we now can document that about a 1/4 of our health departments are no longer providing pre-natal care services.
And previously you heard Dr Anna Sheink[sp?] that research is showing that investment in pre-natal care services in local health departments, is associated with improvements in infant outcomes and so just as you know in 2012, health departments were providing nearly 1/3 of the pre-natal care services in the state.
And in 2014, that number dropped to 36, 000 pregnant women receiving pre-natal care from a high of 42, 000 and fiscal year 2012. So again, funding to local health departments to assure proper maternal health services seems to be an important factor in addressing the overall infant mortality problem.
another protective factor is breastfeeding. And there's a lot of numbers on this fly but basically you look at the first column healthy people 2020 goal. And you can see the goal is to have more than 80% of the women at least initiate breastfeeding. And over the course of time in North Carolina, we've been improving that, we're up to about 77% of women who report at least initiating breastfeeding.
But then if you look down at the last column in North Carolina, you can see how many women stopped breastfeeding by 6 months in 12 months, which is the recommended time and

exclusive breastfeeding meaning no supplement or formula, is actually only at 42% at three months and like 20% at six months.
So we know that breastfeeding is an important protective factor because it's basically baby's fast food, and I know you've been talking about food desserts, and so the first food dessert is breast feeding or lack of breast feeding and so we are continuing to work on efforts to support and promote breast feeding at least through the first six months, it's not 12 months of the baby's life.
So, here is some of the trends, we're still below the healthy people 2020 goal for breastfeeding at three months and six months that we have made improvements on these indicators. We've increased a number of peer counselors in our Wake agencies, so that Breastfeeding Peer Counselor Support Services are available through almost all of our week programs, and hospitals have embraced maternity practices that are mother baby friendly and those of improved breast feeding lexis as well.
We now know that 80% of babies in hospitals now no longer receive a formula discharge bag, and we know that hospital discharge bags with free formula does decrease duration and exclusively the breastfeeding I also what to mention that even the officer state personnel here in North Carolina has a lactation policies for our state employees, and the child care regulations allow mothers to breastfeed in our licensed child care facilities in daycare center so these environmental [xx] changes make a difference in supporting women's efforts to breast feed again you see a lot of variation in breastfeeding practice by the dark areas are, we waited too, the percentage of infants ever breastfed, showing and the highest rates of breastfeeding, and the lighter areas is the lowest and there's some thinking that where there are both board certified lactation consultant and baby friendly care, there's is a greater likelihood to have these breastfeeding rates improved another factor is contraception in the postpartum an important part of ensuring good enough and exceptional cares making sure that women do not have unintended pregnancies which is a respective period the poor birth outcomes.
So, we know that about 50% of our pregnancies are not planned. Access to highly effective means of birth control part of them, visit or are deliveries such as long act and reverse contraception, is really a very effective means to prevent repeat unintended pregnancies so currently in the state if a woman is in medicare she'll maintain her medicare status through six days postpartum and so efforts are under way to sure that she has access to a long acting reverse of contraceptive, so a lot of these contraceptive methods are being provided through local health department if not at the time of delivery.
And what this describes is medic this delivery was covered in the non-emergency Medicaid category. So, women who are unwell for Medic aid when they deliver, they receive emergency medicaid these are women who had medic aid prior to delivery, and you can see the rates of receiving postpartum contraception which is based on claims, Medicaid claims is low, that's the first come, so about 38% or 36%, and then if you look at the long acting and reversible contraceptions which are most effective.
That only about 14%, so we have a long way to go on improving that, and if you look at the last bar, that represents women who receive contraception during the postpartum period even after they had an unintended pregnancy they only about 40% of that population. Now, again, this only represents medicated deliveries, so we would need to be able to look at payers across the state to get a full picture of what's happening in North Carolina, and another reason this is important to do this within the first 60 days is because a lot of women loose insurance coverage after 60 days postpartum and

that impacts also what I'm going to talk about next which is their prevent and health services, so I mention that many women present with a pregnancy and they have a chronic condition, they're not healthy, they have poor nutritional status and ensuring that women are healthy prior to pregnancy is important for healthy pregnancies and healthy babies.
So, here the first graph shows the percentage of women who had a routine preventive health visit or check up in the past year and you can see that the graph represents that more African- American women in 2012 reported receiving a routine checkup about 80% compare to white or Hispanic women. But the numbers are still area for improvement there, and then the second graph shows you women who took a multi-vitamin or folic acid supplement everyday, and that's been improving as well, all women between 15-45 should take folic acid daily because this is the most effective way to prevent births defect.
So as I conclude again I want to emphasize that we do have evidence spaced and evidence in forum solutions to this problems, this may include the five A's which help women stop smoking during pregnancy or the quit line, pregnancy care management which provides the wrap around services for women, particularly low resource women, nurse family partnership where nurses make visits to newborns and mothers following deliveries through the first two years of life, healthy families healthy beginning but there's lots of programs that are available, but we really need to implement this solutions to fit our context, so last time I stated that I thought investing in local communities in the infrastructure at local level is really important and it's still the same here because the problems are very community based and community specific.
And then of course monitoring and evaluating progress is really important into measuring success and continuous quality improvement. Obviously there are a lot of areas where interventions are needed and so in making decisions there are considerations like who is affected, how severe is the problem?
How effective are the innovations? What's the estimated return on the investment? And we know that tools and processes for making these decisions have been used in other states and communities. I do want to mention that the department human services, Division, Public Health has a very preliminary para natal house strategic plan under development, which focuses on a lot of these area and has engaged stakeholders in trying to identify the best strategies to continue to make improvements in infant health.
So in closing the death of a baby signals problems in a community beyond just the death of that infant. Poor birth outcomes have life long ripple effects and cause. North Carolina is currently 40th among all 50 states in infant mortality. We know that strategies require prevention oriented an invention that requires partnership in addition to any medical care.
We know that we have programs and policies that work and that we need sustaining consistent efforts to improve birth outcomes and related therapies, and here again we have to do and offer the right thing. We can't just scar the surface, we need to go deeply and provide the right dose in order to see the results that we want, and then lastly I talked about the gap related to race, ethnicity, poverty, social economic status and I included this slide because I think it's very powerful, it demonstrates that not all babies are starting at the same place, and not all women are starting at the same place and so we may need to adapt our strategies so that we adjust our doses again, and those who need additional resources are able to access that based on what their circumstances are.
So, moving more towards an equity model, I think this is worth consideration.

again I want to acknowledge the department hosting these services, the division of public health and state center statistics for all the data that they provided to make this presentation, and for more information, this is my contact information, and happy to answer any questions, thank you.
Thank you Dr Sclency and this term a four second for any question from the members, Sendra Mekisic. Let me thank you for bringing insightful presentation even though it has some rather women depressing statistics. This thing I was curious about we look at the data you've collected here, is there additional data will kill the correlations between these low birth weight babies, the problems they're experiencing and where they end up 15-20 years down the road.
In terms of health care needs, in terms of drop out rates in school relating to poverty, relating to the likelihood of them repeating this cycle that they were born into. And if so could you share that with this if you have it available or not if you can get it back to us?
I'll be happy to provide you with some research that has tracked the experience of low birth weight infants over the course of their life.
We have that, we talked about the adverse childhood experiences data and then we also have some longitudinal data, so I'm happy to come back with that, get that to you. Thank you and one other follow up Madam Chair, based upon the data you've carried what would see if you had to say that the three greatest priorities that we could focus attention on in terms of policies or funding that will be corrective measures to assist us, and correcting the problems that you identified.
So to respond to that I would go back to this slide that show the causes of infant death and low birth weight and pre-maturity being primary and the risk factors for low birth weight and pre-maturity being the mother's health before pregnancy so investing in women's preventive health services before pregnancy, addressing the risk factors related to smoking alcohol and other drug use, the social support investment are so important because we know that stress, and other negative environmental factors are significant to the birth outcome, and then ensuring that high risk babies are identified before delivery so that they're appropriately cared for at the time of delivery in the right setting.
Last follow up Madam Chair unless simply there's, I didn't determine if there's other states out there that might have undertaken some of these efforts that might specifically target those areas you've just identified that we could look at to see the extent to which they have proven to be effective and reducing or eradicating some of these problems, and do you know that data, the comparative data is available so that we can know where we get a biggest buck to the bank.
I'll be happy to provide that, we do know that there is a quality initiative underway. Maternal Child's Health Bureau is working with North Carolina and other states in the region and identifying strategies to improve infant mortality so we can get that information for you. We tend to look at are region as a comparison because so many of the factors that we are wrestling with are common to states in our region where sometimes looking at other states it's not as comparable so I would suggest looking at what's happening in the region and I would also like to mention,
South East basically, right.
I think North Carolina is a leader in terms of trying to tackle the problem of low birth rate in particular but we can document what's happening in terms of that quality improvement work that's going on. Thank you. Senator Paite Over representative Vinsco, Thank you madam Chairman, and I've some questions on various slides, if I

could follow what on those on slide 25, I think I heard you say that's the one about contraception and the post part on period.
That those were delivered to the health department. The long acting about contraceptives. All of these where they mainly provided through the health department. This data is not just provided through health department, my comment was related to the work that health departments are doing in their communities to ensure that women have access to long acting reversible contraceptives.
So follow up, I guess I'm concerned that we don't have higher numbers because of the medical home model and whether our community care medical homes are doing adequate follow ups. There are these people enrolled in CCNC. My understanding is that there are efforts underway to work with CCNC and medical homes to increase the contraceptive utilization among those women in those medical homes.
And I think that would be good data for us to follow, to see that if we actually get that improvement. Couple other signs follow up. On slide A-18, page 18, I was curious if those were in order of importance or is it just random? It's not order of importance, it's just a list of risk factors that contribute to poor birth outcomes.
And it was meant to maximize the need for preconceptional health services. Because all of these things can be addressed prior to pregnancy. and so that was the intent of this list. Follow up. Thank you. I would just guess that means that the data aren't clear on which is more important. These are factors that we know are preventable and we do know which factors are more significant.
So as I mentioned, smoking is a risk factor in 30% of low birth rate of babies, so smoking is considered a significant risk factor whereas alcohol and substance while they're also risk factors they are not as prevalent among pregnant women. So you'd have to look at the prevalence, so how severe is the outcome because of the risk and then how prevalent, how many people are impacted by it.
So it's a mixed measure if you're trying identify the most important ones. Just a follow up to that question, you mentioned that there's a plan coming over from the department and so my question about smoking especially would be whether or not in that plan will there be any effort to address specifically hooking expectant mothers up with a smoking cessation program or encouraging them to do that or is that already done?
Because I think some of our smoking cessation programs are pretty successful. So the plan does include strategies around substance use, tobacco use and access to services. The draft plan, so it is included under improving health care for women and that is just final. On slide 11 which shows the infant mortality rates by ethnic groups, racial groups I'm curious about the American Indians going up and down so much.
Is that because of reporting inconsistencies or some of the factors. It looks so different from the other lines. I would like to get a follow up about you and and to talk to one of the sad stations because speculary as it is related to smaller numbers and so there's more variation but I would rather talk with somebody it was with that data.
So it was Thank you doctor, I enjoyed your presentation I think when you got to the last slide we kind of diverged onto what I was reading from the data I don't think this is about an equality equity issue. The question is about

how do we go about saving lives of babies in North Carolina and we're talking thousands here.
Look at [xx] slides, there's a what I saw on page 11. The Hispanic community is doing something very right, and if all of the mothers in North Carolina were doing what the Hispanic community is doing, we have one of the best infant mortality rates in the country ahead of much wealthier states than this so, from a private sector point of view, if somebody is doing something a lot better that I am I want to know exactly what they're doing and I will just flat out copy it.
No apologies, I will figure out what they're doing and do exactly that, we're not hearing that, passing it off as cultural differences is not enough. We do have a few slides that say it's not prenatal care, it's not check ups it's, what is it? what exactly are those folks doing that we could go to everybody else in the state, and say copy this if you do this if you live in this fashion I've seen no evidence in as much time as I've spent looking at demographic data I've seen no evidence that as the Hispanic community is a lot better of than the other sub markets and I have seen any information that they are better at tapping into public taxpayer funding programs than other submarket so what are they doing?
Well, they do have a lower smoking rate in their population which contribute to their better outcomes . Secondly they do have family support, community support that protect them somewhat from the stressors that may be other groups of women may experience regardless of their income for social economic status so I would argue that they have few restrictive factors and more protective facotors that seem to enable them to have better pregnancy outcomes.
They did have later entry interprenedal care if you notice so it's complex is a mixture so it's hard to tease out one exact thing that makes the different but I would Think that the smoking and the family support, social support is really important. Yes, is there The way that we can communicate that, if that's the message, if that's what they are doing right how do we get that word out?
Based on what you saying indicating here is not that we need more taxpayer funded programs. We need social support, we need family support we need to stop bad behaviors. So how do we get that message out as opposed to just throwing more money at this?
Well the challenge is that many of these women Hispanic women come to the United States in a healthier status than women who are born here. So as a result because they are healthier and they don't participate in some of these risk factors, risky behaviors they are more likely to have a better birth outcome.
What we have in the United states and North Carolina is generally a population of women who have poor health status and so we have to go back and undo and then move forward and that was really the meaning of the last slide. That not everybody is starting at the same place with respect to their health status and some of their social economic circumstances so I thinks it's hard to compare the health status of Hispanic women and women born here in North Carolina because they're not starting into same place, and unfortunately over the course of a lifetime of health it's going to be very difficult to have a healthy, normal weight baby.
Follow up?
So you're saying Hispanic women are coming here from a third world country for a better way of life, and they are in better health than the native born. They seem to be in better health, yes. Senator Tucker? Thanks you madam, just as a follow up to Senator Wells, Senator Wells, nobody is talking I'll go ahead with my question.

Doctor, thank you for being here, thank you for bringing those things forward I'm not seeing, I hear you're saying smoking cessation, cure management, nurse family, healthy programs, all of this, you didn't bring us a list of things with outcome based evidence that share that the multiple programs that you keep statistics on are available to us to see which ones are more effective than the others.
You didn't do that, is that correct?
The programs I mentioned there is either evidence demonstrating their effectiveness, or their potentially highly effective. There's not the same degree of evidence as some of the other programs, but the ones I mentioned they do have evidence through research that they're effective. Which one is more effective?
Really again it's investing at the community levels depending on the context where these women are living and receiving their health care, so it's hard to have a statewide strategy without understanding some of the yeah you need consideration of the communities that make up the state. All of it?
out of the 118, 000 births that we have here, how many of these were medicaid births? About half as if I thought about time that relates to prenatal physics to public health, meaning these women who were pregnant in all order for the MC receive their benefits for this free stand for the order or ray services that the medicaid provides, they will be require to go to net Physics, I'm just trying to look at some sort of attachment, some kind of ability there for these ladies to make some doe.
My good friends, OBG, Brian Doc retired work two days a week in our health department, and he substantially Is by the way senator Wales for the doctor saying that they've left smoking, and in another factor that he talks about family support and I will just begin Details mean that a lot of fathers whether these folks are married or not, are still around, and still supporting them An African- American impunity nothing against the community but lower part men or not they help take the emotional stress an all the women are just left with that possibility.
So, that family should port peace as their blasphemy Lull Latinos of Catholic, and so with that spiritual peace to it more reference towards the child the male still being around emotional support etc. What she's saying is correct but I'm just asking Anabell, we're talking 56, 000 bolus, here we can tap benefits as we move old with the new system here under [xx] fast we could tie the medicate benefits to whatever they could receive too the fact that they are attending the prenatal [xx] center require to make sure we don't have the issues on the family, I'm just thinking family think someway differently, it just starts and heavens based and in those kind of things people tend to respond and what they don't get they deserve so I thought about up to.
So I want to say first that I think that the pregnancy medical the whole model with the pregnancy care management is trying to identify women who, for whatever reason, may not seek early continuous prenatal care, and provide supportive services to address whatever the areas maybe will there be transportation or not able to get out of work for an appointment, but in thinking about in centers or distance centers to to require women to keep their appointments and go to their visits.
I guess we would say that we want to make sure that our policies don't result in unintended consequences because our goal is to get as many women as possible into high quality prenatal care and so when thinking about policies like that it's important to work it out and see whether it might actually have unintended effect of having fewer women receive adequate care

which is our goal because we want them in our settings so that we can identify their risk factors.
Identify whether the baby needs to be delivered in a high risk facility and make sure that the mother is receiving all the necessary services related to either smoking sensation or nutrition or supportive care. So I would just caution that in looking at policies sometimes what we intend to achieve with them we get the opposite and we don't want fewer babies receiving the appropriate care that they need [xx] up [xx] that we do have a maintain a consequences for lack of accountability now in low birth rates and in birth defects and in a lot these can be avoided by requiring people who are seeking public health to attend this.
And I would ask that you group over Chapel here. I know they're not, we're making it more difficult or whatever, but I can tell you that people that are accountable to their food and their money get motivated to get to public health, and I just think we just give out money and we hold anybody accountable.
I think this would be a motivating factor. Something in next to be able to women to proper health and get them care that they need or their own care can greatly reduce this issue here rather than doing nothing and letting it go on like it's now. We have none intended consequences being 40th in the country right now.
So that's just my point and thought. It's a tough call hard decisions like mine. I think there's probably some credibility thought processed to part two benefits early on, if you're going to receive medicaid and you become pregnant, you must continue a doctor's appointment to continue your benefits, and that's made up up front and it behavior change and that way can possibly help our situation, thank you madam Chair for your indulgence.
Thank you. Well and thank you for having me to apologize that's to the following three speakers, Senator Hays, [xx], and Senator Paints, because we have about 10 minutes. We have to clear out for another committee, and at this time I'll recognize senator Heist Thank madam chairman, just a couple of questions that I had on some of your data points, the first one is around [xx] with county when you're determining counties, what, how do you determine someone's county of residence?
If a child is born in Bangkok or Wake County is it counted toward the birth and bank on my White County because that's where the hospital facility is? Or do you go back to the county the mother originally came from? How is that determination made for someone's county of residence? It's a mothers county of residents.
Follow-up, one of the sides I want to hear real quickly and on 21 and it may just be something to point out for this slide, this looks good. There's a 70 percent receiving care and the first trimester but it's inconsistent with medicate in Romand. We have a three month look back period for a mother who enrolls and Medicaid, and two months after enroll still eligible to receive care.
So, it means a pregnant woman who qualifies for Medicaid will have a minimum of five months of coverage to a maximum of 11 months of coverage on a nine months pregnancy. The average for the state last year was presented as 5.1. The vast majority of medicate and release are enrolled, and show up for the first time at delivery, that was, and so I'm trying to get that with, if we're eligible for care as soon as someone is pregnant in the system.
If they're showing up [xx] they're being enrolled and medicated at that point, and for those types of enrollments, I'm just saying these are inconsistent, with what we see recorded here. So this is not our medicare, this is our resident birth, so if you're asking for information about how this looks for medicare birth we can follow up with that.
I'd appreciate that [xx] but medicare is over half the birth, so medicare in itself would have a huge impact on this and there's a great differences I don't know. I would have to look at that. I'm happy to get that. Is this a pimpleton? Thank you, Madam Chairman.

Question, however to make a little short statement, won't be very long but yeah, this might shock the committee because it has always shocked me but people that work in hospitals on the average by industry are the most obese people in North Carolina.
They have excellent health insurance, and they work in a hospital. Next time you go to a hospital, look at them, that's just a statement I'll follow up. I plead complete ignorance. Why is our babies more healthy when you breastfeed them? The breastfeeding is the first nutritional food so you see in breastfed babies that they have better nutritional status, it prevents infections exposure to illness, they have stronger immunity, immune system and I actually just heard some research that showing a better developmental outcomes for our babies were breastfed.
It's really there are natural food source and they get a lot of benefits from the mother through breastfeeding, there are a number of other benefits as well, sure. Senator Pate. Thank you, Madam Chair. I wish we were able to project two slides at once, but slide 12 and slide 13 cause me a little bit of a problem and we do not have the color zone there on our slide sheets of course.
But looking at 13, that's my section at the State and that the purple is distressing to me. It looks like everything east of where we are here is bad news, and I would like to know what we can do to improve things. I'm sure there's not enough time to. Answer that question but if you would like to take a step in the few remaining moments I would appreciate it.
I think this demonstrates How infant motality is really a measure of overall community health status in that My understanding of this particular area of the state is that, there are possibly more risk factors than protective factors at the community level whether it is related to poverty or lack of access to healthy foods All those social determinants that we talked about, are disproportional y I think evident or education in this eastern part of the state, and so again, in order to improve infant outcomes it will require a comprehensive approach starting with the mother's health in addressing all of those other factors that create risks for her during her pregnancy and delivery.
Follow up? Just a short follow up, but in light of what Senator Wells and Senator Tucker's area, I mean what their subject was about how they the Hispanic population seems to overcome these things, and we have a lot of Hispanics solution part of the state. What's missing? Sir, you probably are not able to move the needle on need for mortality based on the percentage of birth to Hispanic women because it's still a small proportion of birth, and overall just from a statistical point of view, it would be very difficult to see that population actually move the over rate but I think that generally the state has been aware of the charges in that region there have been federal dollars invested in that region to intensify some of the informality prevention work, and it's just going to take a long time with consisting investment to see changes, I mean there been improvement in that area as well as other areas of the state, it's just not been as quick and they, the catch up for those women

and children is greater because they're not starting at the same place as women and kids who are in central part of the state.
so I think it's improving, but it's going to take continued investment in a long view. That is the end of the list. Is there anyone who been closing would like to make a comment or ask a question that just crossed their mind? OK, it's not Dr. Solente. Thank you so much for your presentation and considering the direction we're going with the committee, this particular budget cycle we plan to see a lot of you, I'm sure.
Thank you again so much to everyone and we stand adjourned. try to get this committee meeting

going, thank you we thank you for being here, I want to make aware we do have a sergeant at arms who are here with us, we appreciate that young Bay, Bill Mavers and John Marren looked around. I did not see any pages and I don't understand that because this is a very exciting committee meeting and certainly can learn a lot so they must be busy in other areas, but we do not have any pagers with us, will see if they will join us in the future.
We only have one bill in front of this committee pass bill 119 and I will call on the bill sponsors to come up and briefly present to us this bill thank you Mr. Chairman, good morning members, ladies and gentlemen, this bill is result of PED program evaluation oversights study that was done in 2013, 2014.
The 2013 budget bill required PED to review impatient alcohol and drug abuse treatment programs across our state. This bill was approved or the study was approved by the Joint Legislature Program Evaluation Oversight Committee and they conducted it obviously that's why we have a bill. PED found that there were two primary problems, so this bill addresses these two primary problem, first the state run alcohol and drug abuse treatment centers commonly known as Aidax operate autonomously from the community based system.
The separation limits North Carolina ability to address service gaps, to know where they are and to provide addressed of the providing a seamless continuum of care and manage the high cost of inpatients substance abuse treatment. Also North Carolina performance management system for substance abuse treatment has long, excuse me, it's been a long morning already, lack long term outcome data.
PD therefore made two recommendations. First, because of the autonomous operation of the ADACTs the coordination challenges are just coordination challenges and they incentivise over utilization of ADACTs in North Carolina. North Carolina should gradually integrate the ADACTs into the North Carolina community-based substance abuse treatment systems that require LME-MCOs to pay for and manage ADACTs utilization.
And second, the division of middle health development disabilities and substance abuse services should strengthen its performance management system by improving data collection and tracking long term outcomes. We were just talking a few minutes ago I was just talking with Rocio[sp?] Avalos[sp?] about the lack of good data and knowledge of how all this comes together, and the need for that.
This bill does not, I emphasize, not, reduce dollars spent on treatment, but instead allows the LME MCOs to allocate the substance abuse treatment dollars to where they are most needed. So for few more details on the bill and by the way as you may already know we presently have three aid acts across North Carolina, we have I believe Nine LME MCOs operating these services by consolidating these, we'll get a better handle on what the challenges as well as the opportunities and add some efficiencies to the system so that we can better utilize every available dollar and every available bed, and those cases where we need more of this or that of the other, we can identify that clearly and then takes appropriate actions.
With that, Mr. Chairman I'd like to ask thankyou [xx] we will ask that for you, give a standard view representative Dolph. Well, I'd be happy to provide a favorable motion is, soon as you're ready for it, I mentioned to the bills sponsoring, to another member that I had a

question about a section, but I got that question answered.
Okay. Why don't we go out make that motion and we'll come and let's [xx] and see if there's any public comment. Well, I would reports on house bill 119 with the refer to the committee on the preparation representative Martin. Thank you Mr. Chair. Just a quick question, has there been feedback from these organizations and from the LMEMCOs, like what kind of response have you gotten and can you just share that?
In the in the report itself that's produced by PED, a copy of which I thought I had right here in my pocket but you'll see in the report as you may know a PED they always send their reports and recommendation to the affected agencies and then include their response [XX] in the report and as I read the response, this is the report which's available both online or hard-copy, down as PED when you go right to the back page, there is a response from North Carolina department health and human services division of state operated health care facilities, dated November 12th, signed by Dale Armstrong the division director, and as I was up I went three times I discern no real push back and they appreciated the result of the report, I've not been approached or heard of any push back on the bill or recommendation in response, brief presentation by staff xx present there, okay .
I'll be happy to do that Mr. Chair, you'll notice I'm just going to really go quickly through the bill and if there're any questions for more information I'm happy to provide that, you'll notice the bill is organized into eight different parts the first part is just the definition section, I know for many of us who work in [xx] we've a lot of abbreviation to keep up with so that's what part one of the bill is.
Part two of the bill establishes that the intent is to integrate the Adax into the LME/MCO system over a three year period, beginning July 1, 2016, with full integration June 30th, 2019, part two contains a reporting requirement for [xx] to the joy it was, just saver every syke.communal health and human services with regard to the three year transition business plan, you can see that reports due by April 1st, 2015, and it contains some bullet points.
If you want to look at the summary, projected demand, projected availability, procedures for making operational adjustments, methodology for establishing and outdating rate, and a uniform process for the LME MCOs to get prior authorization. Those are some of the things that need to be in the three year transition business plan that's reported April 1st part 3 provides background information formation and requirement regarding termination and reallocation of direct state appropriation.
It requires the LME MCO an opportunity to plan for the official and effective management of reallocated funds and has several different reports recording date you will see on the second page on the bill summary just to make sure that the general assembly is aware of how things are moving along and the LMCO know what their funding id going to look like and complain accordingly.
Part four provides for the LMEMCO payment utilization managemnet for aid act services again you'll see reporting requirements in there, part five adjustment of the aide act operations. It provides for the intent for the eight act to be holly receipt supported by the end of the transitions period period and the eight at most annually evaluate and adjust their operations based on projected demand for services and availability of funding from direct State Appropriations and Estimated Receipts.
Parts six provides over-side reporting that during the transition plan, the division of middle health development disability from substance abuse sources must monitor, and it provides the list of things including expenditures of the LME'S, which make sure it meets maintenance of effort requirement.
Efforts for LMENCO to increase capacity for substance community abuse treatment and development of community-based services and utilization of element E, MCO of substance abuse services provide about the eight act, then we getting

on October 1st 2016 and annually there after DHHS members report to the over-site committee on health and human services through October 1st 2020 and finally part seven is the second issue that representative foreign mentioned that has to do with performance management and the strengthening of performance management, provides that by January 15, 2016, division of middle health and consultation with LME-MCOs must have developed and submit to oversight committee.
A plan to street and performance management for the sate probably funded substance abuse services and it outlines five things that the plan must include and the bill will become effective when it becomes law we happy to answer any further questions. Thank you Mrs. Matilda. I believe we do have maybe one or two from the public who would like to speak and if you would like to speak you'll come forward to the microphone make sure you push the button.
And now you have three minutes I give you the opportunity to make some comments, if you would identify yourself as well. Thank you Mr. Chairman. My name is Mark I represent the Addiction Professionals for North Carolina our organisation represents the interest of over 6000 addiction professionals including those in treatment, those dealing with prevention issues, and research around alcoholic and substance abuse issues .
Our organisation is not opposed to this bill we are especially pleased with the provisions around, additional data collection we believe that that's very important, however for we do believe and I think many of you well have brought up additional concerns about the pace of this and other questions that may need to be answered before the full process of changing has been done, in the report you'll note that there're a number of different questions around the community capacity to provide the continue home care that maybe be available in some areas least but not as available in others, I think that an area that clearly we need to address, this particular bill does not necessary as Representative Poe said, it does not necessarily pull the rug out from the ADACTs, but it does potentially create some problems for those who now have a specially do-or-die diagnosis of substance abuse issues along with mental health issues.
We simply need to make sure that our LMEs and MCOs have the capacity to deal with those particular types of clients. and frankly I think in a lot of those LMEs and MCOs, they do have that capacity, but that might not be as well spread as we would like in addition to that we need to make sure that providers are aware of this particular change and again we're not opposed to this bill we will say and I think it's very important as the report noted that the folks who are served in the [xx] We tend to be those with the most significant problems, those with no insurance, those with no other place to go and we simply need to make sure that there're provisions available.
closer is better and so if those communities capacities are there we should use them, if not the A-desk on [xx] Thank you. Thank you Mr. Xx
Other comments in the public?
Yes, good-morning My name is xx I represent along with my colleague Ashley Perkinson Triangle Residential Options for Substance Abusers TROSA. Which is a licensed residential therapeutic community in Durham that serves the entire state, we also have no complaints with the Bill we applied the effort to build community based capacity, we're part of the solution we provide that community based capacity for all North Carolina counties currently, for two year 24 seven long term residential and vocational training, we provided those services since the early 90's.
80% of the revenue that ROSA generates is generated by the vocational programs, the businesses that it operates with assistance service residence, less than or about 3% of those $14 million dollar annual budget is provided by the state, none of that funding which is about $350, 000 it comes through the LMEs', it's a direct appropriation, a direct pass through, we are up the limit basically of our capacity to provide these

community based services again to all of are North Carolina counties as well as the court systems and the prison systems, I guess the messenger want to leave you with is, we'd like to continue the conversation with representative Warren, and representative Vavoy[sp?] and all of you of the when you move the resources out of the facilities and into the community, we would like to be part of the conversation about that capacity because, but currently if you move those resources out of the facilities and into the LMEs, we the License Therapeutic Communities in the state do not receive any support from the LME, so we would continue to be isolated from that funding support while we were providing exactly the kind of services that you're trying the build with this legislation, so we want to continue the conversation about how those license therapeutic communities can be included in the effort to build more capacity.
Thank you very much. Thank you. Anyone else? First Mr. Armstrong is here if he will like to say anything. Thank you for being here. is it working?
Thank you Chairman Lambert, Dale Armstrong division director State Operated Health Care Facilities. Just a couple of points for clarification that I'd like to make, one is that we do and have a round record as not opposing this plan to move forward its been presented by PED we think it makes sense.
We look forward to working with the General Assembly and other stake holders in moving along this path, we do have some significant concerns regarding the implementation plan that is associated with the PED recommendation. We feel that the proposed implementation plan is not a plan that will enable us or the communities to have a smooth transition of these services over the poor your period also want to make a note that the 196 beds that AIDAX represent are a significant and a vital resource in our continuum of care as a general assembly is aware back in the mid-2000s we reduced a significant number of inpatient beds in our state hospitals.
During that period of time, I was recognized that the AIDAX could help absorb some of that capacity which in fact they had done and they continued to do, so we just feel we need to be very conversant of the fact of the rules that the index players we move forward in a transition and not end up in a situation where our capacity has been limited by inadvertently negatively impacting the beds and the aid aidax and then resulting in a significant increase in the number of patients that are back lambed in our communities ED's, thank you Mr. Chairman.
Thank you Mr. Armstrong and thanks for the work you do, yes mum. Thank you Mr. Chairman I'm Weigh Right I'm the executive director of these Carolina behavior of health and we are one of the nine LMEMCO's across the state. I would just like to say in response to Representative Martin's query, the LMM, MCOs are also in favor of this transition.
The general assembly has entrusted us with public management of the behavioral health, and intellectual, and developmental disability services. And we think that having that continual of care under that management structure makes a lot of sense, and we will enable us to ensure that people move from the highest level of service at the alcohol and drug abuse treatment centers into an appropriate communities after care service in a much more seamless and efficient manner and so we appreciate that opportunity, thank you.
Thank you, thank you for what you do as well. Okay, we've had a motion, they will report with [xx] all those and save as they are in your pause, meeting's adjourned, thank you very much [xx]